Finding into death of Pedro Arcos-Vazquez

41y · Male·Incised injury to the neck

Pedro Arcos-Vazquez, a 41-year-old man with a history of depression, was killed by a boardhouse resident with a psychiatric history. The resident had been discharged from a Community Treatment Order (CTO) on 27 October 2010 and care transferred to his GP, Dr K., without a discharge plan or transition period. On the day of death, the resident presented to police mentioning he might kill someone, appeared psychotic, underwent psychiatric assessment, and was released. Shortly after, he killed Pedro with multiple incised injuries. The coroner found the CTO discharge decision lacked input from the treating psychiatrist and the CTO had been ineffective due to lack of consequence enforcement. A discharge plan and proper transition should have been prepared. The coroner found no evidence that police could have acted differently, nor that Champix contributed to the violent acts. The resident's vulnerability and psychiatric condition warranted continued structured care rather than autonomy in treatment decisions.